Cardiology Flashcards
1
Q
Management for quitting smoking
A
Nicotine gum
Varinicline - oral selective nicotine receptor antagonist
Bupropion - shown to reduce smoking
2
Q
When a patient describes chest pain, you’re worried about
A
Pulmonary embolism
MI
Dissecting aortic aneurysm
Pericarditis
3
Q
Constricting chest pain
A
Angina, oesophageal spasm or anxiety
4
Q
Sharp chest pain
A
From pleura or pericardium
5
Q
Prolonged, dull, crushing chest pain
A
MI
6
Q
Cardiac ischemia can radiate
A
To shoulders, either arms, neck and jaw
7
Q
Dissecting aneurysm can radiate to
A
Infra scapular or retro sternal
8
Q
Epigastric pain
A
Can also be cardiac
9
Q
Pain caused by exercise, mood, cold
A
Either cardiac or anxiety
10
Q
Pain caused by meals, lying flat or hot drinks
A
Gastric
11
Q
If glycerol trinitrite resolves pain quickly
A
It’s angina,
If slowly, it’s oesophageal spasm
12
Q
If antacids relieve pain
A
It’s gastric
13
Q
If pain improves on leaning forward
A
Suspect pericardiac causes
14
Q
Causes of dyspnoea
A
Pulmonary embolism Respiratory cause Anxiety LVF Pericardiac causes Pleursy
15
Q
Symptoms of MI
A
Vomiting
Nausea
Sweating
16
Q
Causes of Angina
A
Coronary heart disease
Aortic stenosis
Hypertrophic cardiac myopathy
Paroxysmal supra ventricular tachycardia
17
Q
Patient presents with Dyspnoea
Ask about:
A
Shortness of breath at rest, on exertion, on exercise
Is it episodic
Triggered by lying flat
18
Q
Dyspnoea is associated with
A
Cardiac failure
Pillows at night (orthopnoea)
Gasping for breathing, waking up at night (paroxysmal dyspnoea)
Peripheral oedema
19
Q
What to do with an acutely Ill patient
A
Admit to hospital Check BP, JVP, heart sounds, DVT O2 mask, IV line Relieve pain Cardiac monitor
20
Q
Causes of palpitations
A
Ectopics AF SVT VT Thyroid toxicity Anxiety
21
Q
Syncope can be caused by
A
Cardiac or CNS reasons
22
Q
Symptoms for cardiac syncope
A
Chest pain, palpitations, dyspnoea,
23
Q
What to ask patients with syncope
A
Pulse?
Limb jerking, urinary discharge, tongue biting
Recovery time
Rapid or prolonged
24
Q
slight but regular lengthening and then shorten- ing (with respiration)
A
Sinus Arrhythmia, common in children
25
P wave (upright in II, III, & aVF; inverted in aVR) followed by a QRS complex.
Sinus rhythm
26
Sawtooth ECG
Atrial flutter
27
no discernible P waves and QRS complexes are irregularly irregular
Atrial fibrillation
28
normal QRS complex but P waves are absent or occur just before or within QRS complexes
Nodal rhythm
29
QRS complexes >0.12s
with P waves following them
Ventricular rhythm
30
Left axis deviation of the mean frontal axis of an ECG is caused by
LVH, left anterior hemiblock, inferior MI, VT from LV focus, Wolff–Parkinson–White (WPW) syndrome (some types).
31
Right axis deviation of the mean frontal axis of an ECG is caused by
RVH, PE, anterolateral MI, left posterior hemiblock (rare), WPW syndrome (some types)
32
Causes of absent p wave
AF, sinoatrial block, junctional (AV nodal) rhythm.
33
Dissociation between p wave and qrs
Heart block
34
What is p mitrale and a likely cause
bifid P wave, indicates left atrial hypertrophy
35
What is p pulmonale and a likely cause?
peaked P wave, indicates right atrial hypertrophy.
36
What is a PR interval and what is it's normal range?
Measure from start of P wave to start of QRS. Normal range: 0.12–0.2s (3–5 small squares).
37
What does a long PR interval indicate
1st degree heart block
38
What does a short PR interval indicate
unusually fast AV conduction down an accessory pathway, eg WP
39
What can a qrs complex of >0.12s suggest?
ventricular conduc- tion defects, eg a bundle branch block
40
What does a large qrs complex suggest?
Ventricular hypertrophy
41
Pathological q waves occur
After MI
| Normal Q wave
42
What is a qt interval and it's normal range?
Measure from start of QRS to end of T wave
43
Prolonged QT interval can be caused
acute myocardial ischaemia, myocarditis, bradycardia (eg AV block), head injury, hypothermia, U&E imbalance (reduced K+, Ca2+, Mg2+), congenital (Romano–Ward and Jervell–Lange–Nielson syndromes, p724); sotalol, quinidine, antihistamines, macrolides (eg erythromycin), amiodarone, phenothiazines, tricyclics.
44
ST segment is usually
Isoelectric. Raised or depressed st segment indicates ischemia or infarct
45
Peaked t wave indicates
Hyperkalaemia
46
Depressed t wave indicates
Hypokalaemia
47
J wave I seen only in
Hypothermia, hypercalemia and subarachnoid haemorrhage
48
Define sinus tachycardia and it's causes
Anaemia, anxiety, exercise, pain, T°, sepsis, hypovolaemia, heart failure, pulmonary embolism, pregnancy, thyrotoxicosis, beri beri, CO2 retention, autonomic neuropathy, sympathomimetics, eg caffeine, adrenal- ine, and nicotine (may produce abrupt changes in sinus rate, or other arrhythmia).
49
In the obese, an AAA
Can be impalpable
50
Groups of patients that tend to present with atypical chest pain
Women and diabetics
51
In patients with MI the apex beat is
Lower and more lateral because of dead and floppy cardiac muscle
52
Name 3 common causes of atrial fib
IHD, thyrotoxicosis, hypertension.
53
What's the sign of 3rd degree heart block and the common causes?
Absent p wave
IHD, idiopathic (fibrosis), congenital, aortic valve calcification, cardiac surgery/trauma, digoxin toxicity, infiltration (ab- scesses, granulomas, tumours, parasites).
54
What's a pathological q wave and what can cause it?
Pathological Q waves are usually >0.04s wide and >2mm deep. Usually as sign of infarction, and may occur within a few hours of an acute MI. Non-pathological Q waves may occur in V5 and V6, aVL and I.
55
What can cause a raised st interval?
Normal variant (high take-off), acute MI, Prinzmetal’s angina (p722), acute pericarditis (saddle-shaped), left ventricular aneurysm.
56
What can cause a depressed st interval?
Normal variant (upward sloping), digoxin (downward sloping), ischaemic (horizontal): angina, acute posterior MI.
57
What can cause a t wave inversion?
T inversion: In V1–V3: normal (black patients and children), right bundle branch block (RBBB), pulmonary embolism. In V2–V5: subendocardial MI, HCM, subarachnoid haem- orrhage, lithium. In V4–V6 and aVL: ischaemia, LVH, associated with left bundle branch block (LBBB).
58
What's seen in an ECG after an MI
Within hours, the T wave may become peaked and ST segments may begin to rise.
• Within 24h, the T wave inverts, as ST segment elevation begins to resolve. ST eleva-
tion rarely persists, unless a left ventricular aneurysm develops. T wave inversion
may or may not persist.
• Within a few days, pathological Q waves begin to form. Q waves usually persist, but
may resolve in 10% of patients.
• The leads affected reflect the site of the infarct: inferior (II, III, aVF), anteroseptal
(V1–4), anterolateral (V4–6, I, aVL), posterior (tall R and ST in V1–2), and thus the oc- cluded vessel: left anterior descending (anteroseptal), right coronary (inferior or right ventricular), circumflex (posterior, and, in 20%, inferior termed ‘left domi- nance’) .
59
What's seen in an ECG on a pulmonary embolism?
Sinus tachycardia is commonest. There may be RAD, RBBB (p91), right ventricular strain pattern (R-axis deviation. Dominant R wave and T wave inversion/ST depression in V1 and V2. Leads II, III and aVF may show similar changes). Rarely, the ‘SIQIIITIII’ pattern occurs: deep S waves in I, pathological Q waves in III, inverted T waves in III.
60
What's the digoxin effect?
Digoxin effect: ST depression and inverted T wave in V5–6 (‘reversed tick’). In digoxin toxicity, any arrhythmia may occur (ventricular ectopics and nodal bradycardia are common). Hyperkalaemia: tall, tented T wave, widened QRS, absent P waves, ‘sine wave’ appearance
61
Where do you place the chest leads?
V1: right sternal edge, 4th intercostal space
V2: left sternal edge, 4th intercostal space
V3: half-way between V2 and V4
V4: 5th intercostal space, mid-clavicular line;
all subsequent leads are in the same horizontal plane as V4
V5: anterior axillary line
V6: mid-axillary line (V7: posterior axillary line)
62
What's a cardiac catheterization
This involves the insertion of a catheter into the heart via the femoral or radial artery or venous system, and manipulating it within the heart and great vessels to
63
Purpose of catheterization
• Sample blood to assess oxygen saturation and measure pressures (see BOX).
• Inject radiopaque contrast medium to image cardiac anatomy and blood flow.
• Perform angioplasty (± stenting), valvuloplasty, and cardiac biopsies, or to do pro- cedures, eg transcatheter ASD closure.
• Perform intravascular ultrasound or echocardiography.
64
What are the complications associated with cardiac catheterization
Complications:
• Haemorrhage: Apply firm pressure over puncture site. If you suspect a false aneu-
rysm, ultrasound the swelling and consider surgical repair.
• Contrast reaction: This is usually mild with modern contrast agents.
• Loss of peripheral pulse: May be due to dissection, thrombosis, or arterial spasm.
Occurs in 24h, take blood cultures before giving antibiotics.
65
What is intra-cardiac electrophysiology
This catheter technique can determine types and origins of arrhythmias, and locate (and ablate) aberrant pathways (eg causing atrial flutter or ventricular tachycardia). Arrhythmias may be induced, and the ef- fectiveness of control by drugs assessed. Radiofrequency ablation may be used to destroy aberrant pathways or to prevent AF.
66
What is CT angiography and what is it used for
CT angiogram permits contrast-enhanced imaging of coronary arteries during a single breath hold. It can diagnose significant (>50%) stenosis in CAD with an accuracy of 89%. Its negative predictive value is >99%, which makes it an effective non-invasive alternative to routine coronary angiography to rule out CAD
67
Chief risk factor for IHD
Smoking
68
What is Aspirin, how does it work and who's it for?
Anti platelet drug,
Aspirin irreversibly acetylates cyclo-oxygenase, preventing pro- duction of thromboxane A2, thereby inhibiting platelet aggregation. Used in low dose (eg 75mg/24h PO) for secondary prevention following MI, TIA/stroke, and for patients with angina or peripheral vascular disease. May have a role in primary prevention.15 ADP receptor antagonists (eg clopidogrel, prasugrel) also block platelet aggregation, but may cause less gastric irritation.
69
What is Warfarin, how does it work and who's it for?
Anticoagulant,
| Warfarin (p344) is mainly used in AF, and with mechanical valves.
70
What are beta blockers, how does it work and who's it for?
Block -adrenoceptors, thus antagonizing the sympathetic nervous system. Blocking 1-receptors is negatively inotropic and chronotropic (pulse by firing of sinoatrial node), and 2-receptors induce peripheral vasoconstriction and bronchoconstriction. Drugs vary in their 1/2 selectivity (eg propranolol is non-se- lective, and bisoprolol relatively 1 selective), but this does not seem to alter their clinical efficacy. Uses: Angina, hypertension, antidysrhythmic, post MI (mortality), heart failure (with caution). CI: Asthma/COPD, heart block. Caution: Heart failure (but see carvedilol, p130). SE: Lethargy, erectile dysfunction, joie de vivre, nightmares, headache.
71
Expiration increases blood flow to which side of the heart
Left, because thoracic cavity reduces in size
72
How do loop diuretics work and what are they used to treat?
Loop diuretics (eg furosemide) are used in heart failure, and inhibit the Na/2Cl/K co-transporter. Thiazides are used in hypertension and inhibit Na/Cl co- transporter. SE: Loop: dehydration, K+, Ca2+, ototoxic; thiazides: K+, Ca2+, Mg2+, urate (±gout), impotence (NB: small doses, eg chlortalidone 25mg/24h rarely cause significant SEs); Amiloride: K+, GI upset.
73
How do vasodilators work and what are they used to treat?
Used in heart failure, IHD, and hypertension. Nitrates preferentially dilate veins and the large arteries, filling pressure (pre-load), while hydralazine (often used with nitrates) primarily dilates the resistance vessels, thus BP (after- load). Prazosin (an -blocker) dilates arteries and veins.
74
What is mitral stenosis and what are it's causes
Mitral stenosis is narrowing of the mitral valves
Rheumatic, congenital, mucopolysaccharidoses, endo- cardial fibroelastosis, malignant carcinoid (p278; rare), prosthetic valve.
75
What are other signs of mitral stenosis?
Malar flush on cheeks (due to cardiac output); low-volume pulse; AF common; tapping, non-displaced, apex beat (palpable S1). On auscultation: loud S1; opening snap (pliable valve); rumbling mid-diastolic murmur (heard best in expiration, with patient on left side). Graham Steell murmur (p44) may occur. Severity: The more severe the stenosis, the longer the diastolic murmur, and the closer the open- ing snap is to S2.
76
What investigations should be done after auscultation a murmur?
ECG
| Echocardiogram
77
What is mitral regurgitation?
Turbulent flow of blood due to back flow because of failure of closure of mitral valve
78
What are the causes of mitral regurgitation?
Functional (LV dilatation); annular calcification (elderly); rheumatic fever, infective endocarditis, mitral valve prolapse, ruptured chordae tendinae; papillary muscle dysfunction/rupture; connective tissue disorders (Ehlers–Danlos, Marfan’s); cardiomyopathy; congenital (may be associated with oth- er defects, eg ASD, AV canal); appetite suppressants (eg fenfluramine, phentermine
79
What are the symptoms and signs of mitral regurgitation?
Symptoms: dyspnoea, palpitations, fatigue, infective endocarditis
Signs: AF
Pan systolic murmur that radiates to axilla
80
What are common causes of mitral valve prolapse?
ASD, patent ductus arteriosus, cardiomyopathy, Turner’s syndrome, Marfan’s syndrome, osteogenesis imperfecta, pseudoxanthoma elasticum, WPW
81
What are the signs and symptoms of mitral valve prolapse?
Symptoms: asymp, chest pain, palpitations, autonomic dysfunction
Signs: mid systolic clic or late systolic murmur
82
What are the complications of mitral valve prolapse?
Mitral regurgitation, cerebral emboli, arrhythmias, sudden death.
83
What is aortic stenosis, and name some common causes
Aortic stenosis is narrowing of the aorta, and it's caused by Senile calcification is the commonest.96 Others: con- genital (bicuspid valve, William’s syndrome, p143), rheumatic heart disease.
84
What are the common signs and symptoms?
Symptoms: angina, chest pain, breathlessness, syncope, dizziness, sudden death, emboli,
Signs:Slow rising pulse with narrow pulse pressure (feel for diminished and delayed carotid upstroke—parvus et tardus); heaving, non-displaced apex beat; LV heave; aortic thrill; ejection systolic murmur (heard at the base, left sternal edge and the aortic area, radiates to the carotids).
85
What is Aortic sclerosis?
senile degeneration of the valve. There is an ejection systolic murmur, no carotid radiation, and normal pulse (character and volume) and S2
86
What are the common causes of aortic regurgitation
Acute: Infective endocarditis, ascending aortic dis- section, chest trauma. Chronic: Congenital, connective tissue disorders (Marfan’s syndrome, Ehlers–Danlos), rheumatic fever, Takayasu arteritis, rheumatoid arthritis, SLE; pseudoxanthoma elasticum, appetite suppressants (eg fenfluramine, phenter- mine), seronegative arthritides (ankylosing spondylitis, Reiter’s syndrome, psoriatic arthropathy), hypertension, osteogenesis imperfecta, syphilitic aortitis
87
What are the symptoms of aortic regurgitation?
Symptoms: Exertional dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea. Also: palpitations, angina, syncope, CCF. Signs: Collapsing (water-hammer) pulse (p40); wide pulse pressure; displaced, hyperdynamic apex beat; high-pitched early diastolic murmur (heard best in expiration, with patient sitting forward). Eponyms: Corrigan’s sign: carotid pulsation; de Musset’s sign: head nodding with each heart beat; Quincke’s sign: capillary pulsations in nail beds; Duroziez’s sign: in the groin, a finger compressing the femoral artery 2cm proximal to the stethoscope gives a systolic murmur; if 2cm distal, it gives a diastolic murmur as blood flows backwards; Traube’s sign: ‘pistol shot’ sound: over femoral arteries; an Austin Flint murmur (p44) denotes severe AR.
88
What is the definition of heart failure?
Cardiac output of heart is insufficient for the body's needs. Typically poor prognosis.
89
What is systolic heart failure and what are the possible causes?
inability of the ventricle to con- tract normally, resulting in cardiac output. Ejection fraction (EF) is
90
What is diastolic failure and it's causes?
Failure of ventricles to relax normally, causing lower filling pressure.
Causes: constrictive pericarditis, tamponade, restrictive cardiomyopathy, hypertension. NB: systolic and diastolic fail- ure usually coexist.
91
Left sided heart failure causes
Pulmonary oedema, breathlessness, poor exercise tolerance, pink frothy sputum, weight loss, muscle wasting
92
What are some of Right sided heart failure's causes and symptoms?
Causes: LVF, pulmonary stenosis, lung disease
Symptoms: Ascites, peripheral oedema, tricuspid regurgitation, nausea, anorexia
93
What is WPW caused by?
Abnormal accessory conduction pathways between the atria and ventricles which can stimulate the ventricles prematurely
94
What can be seen in the ECG of a patient with WPW
A special type of supra ventricular tachycardia, called atrioventricular reentrant tachycardia
95
What are the symptoms of WPW?
Usually asymptomatic, but palpitations, dizziness, SOB and syncope can occur during an SVT
96
What is a bundle branch block?
A defect in the bundle branches in the electrical conduction system of the heart
97
What can a bundle branch block cause?
Loss of ventricular synchronization
98
What can be seen in the ECG of a right bundle branch block?
Axis of ECG shifts to the right
| Qrs complex is >120s. (Last part is elongated)
99
What can be seen in the ECG of a left bundle branch block?
Axis of ECG shifts to the left
| Qrs complex is >120s. (Entire qrs wave is elongated)
100
What is WPW caused by?
Abnormal accessory conduction pathways between the atria and ventricles which can stimulate the ventricles prematurely
101
What's associated with aortic stenosis?
Syncope
Exertional dyspnoea
Angina
102
What is valvuloplasty and what is it used for?
A balloon catheter is inserted into the valve and inflated
| Used in mitral pulmonary regurgitation
103
What is the clinical presentation of infective endocarditis?
Fever, rigors, sweating, finger clubbing, murmurs, janeway lesions, Roth spots, oslers nodes, malaise, weight loss, anaemia
104
What are the common causes of infective endocarditis?
Strep veridans, Staph aureus, diphtheroids
105
What is acute myocarditis?
Inflammation of myocardium
106
What are the causes of acute myocarditis?
Viral infection (polio, flu, hepatitis, coxsackie, HIV, mumps) bacterial infection(diphtheria, clostridium, TB, meningococcus), drugs (sulphonamide, penicillin, cyclosphamide, herceptin)
107
What are the signs and symptoms of acute myocarditis?
Dyspnoea, chest pain, soft S1, galloping S4, fatigue, fever, palpitations, tachycardia
108
What can be seen in the ECG of someone with acute myocarditis?
St elevation or depression, t wave inversion, arial arrhythmia, transient AV block
109
What is dilated cardiomyopathy?
A dilated, flabby heart of unknown causes
110
What is dilated cardiomyopathy associated with?
Alcohol, thyrotoxicosis, pre or post partum, haemochromatosis, congenital, autoimmune, hypertension
111
What is the clinical presentation of cardiomyopathy?
Raised JVP, RHF, VT, AF, hypotension, S3 gallop, pulmonary oedema, oedema, fatigue, dyspnoea, mitral or tricuspid regurgitation, jaundice, Hepatomegaly
112
A cause of sudden cardia c death in the young could be:
Cardiac hypertrophy
113
What are the causes of restrictive cardiomyopathy?
Idiopathic, amyloidosis, haemochromatosis, sarcoidosis, scleroderma, Löeffer's eosinophilia endocarditis, endomyocardial fibrosis
114
What is the presentation of restrictive cardiomyopathy?
Like RVF: raised JVP, Ascites, oedema
115
What are the clinical features of acute pericarditis?
Central chest pain worse on inspiration or lying flat ± relief by sitting forward. A pericardial friction rub may be heard. Look for evidence of a pericardial effusion or cardiac tamponade (see below). Fever may occur.
116
What is a pericardial effusion?
Accumulation of fluid in the pericardial space
117
What are the clinical features of a pericardial effusion?
Central chest pain worse on inspiration or lying flat ± relief by
sitting forward. A pericardial friction rub (p44) may be heard. Look for evidence of a pericardial effusion or cardiac tamponade (see below). Fever may occur.
118
What is constrictive pericarditis?
The heart in encased in a stiff pericardium
119
What are the clinical features of constrictive pericarditis?
These are mainly of right heart failure with JVP (with prominent x and y descents, p41); Kussmaul’s sign (JVP rising paradoxically with inspiration); soft, diffuse apex beat; quiet heart sounds; S3; diastolic pericardial knock, hepato- splenomegaly, ascites, and oedema.
120
What is cardiac tamponade?
Accumulation of pericardial fluid raises intrapericardial pres- sure, hence poor ventricular filling and fall in cardiac output.
121
What are the clinal features of cardiac tamponade?
Pulse, BP, pulsus paradoxus, JVP, Kussmaul’s sign, muffled S1 and S2. Diagnosis: Beck’s triad: falling BP; rising JVP; muffled heart sounds.
122
What are the causes of raised JVP?
```
HF
Constrictive pericarditis
Cardiac tamponade
SVC obstruction
Fluid overload
```
123
A narrow complex tachycardia that reverts to sinus rhythm after the valsalva manoeuvre is
AV nodal re entry tachycardia
124
A young man with central chest pain and breathlessness with a history of sore throat likely has
Acute pericarditis
125
What it's the most likely cause of an ejection systolic murmur?
Aortic stenosis
126
If a tachycardia is resolved by adenosine it is caused by
The AV node, as adenosine blocks the AV node allowing sinus rhythm to return
127
What MI causes Bradycardia and why?
Inferior MI
| As the r. Coronary artery supplies the SA node in most people
128
What is the treatment of broad complex tachycardia?
Amiodarone
